Information Technology

  • General Application Information

  • (Sole Proprietor, Corporation, Partnership, LLC, etc)
  • (Describe typical services performed, customers served, products provided, etc.)
  • Sales Breakdown by % of revenue

  • Consulting and miscellaneous IT Services

  • Web casting and conferencing

  • Network Service or Access

  • Computer Manufacturing and Assembly

  • Total for the breakdowns above (should add up to 100%)
  • Current Insurance Information

  • Note: Complete below or fax us your loss runs at 301-417-0040
  • Location / Building Information

  • If over 30 years old, years of updating for


  • Coverage/Rating Basis Information

  • Property

  • Should include Leasehold Improvements(may also be included in building so obtain a breakdown), Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, Property of Others
  • General Liability

  • Worker's Compensation by State


  • Owner/Officer Information


  • Automobile

  • Owned Vehicle Schedule

    NOTE: You may complete with Vehicles and Drivers below, or fax us your list at 301-417-0040

  • Drivers Schedule (if you own vehicles)

    (List all employees who drive any vehicle on company business)

  • Prior Claim/Loss Information

  • Other Optional Coverage to Consider